Furthermore, immunosuppression should be reduced until the CMV infection is controlled.27

Epstein Barr virus (EBV) associated infection can initiate an entire spectrum of disease. Those particularly at risk are recipients who are EBV negative and who receive an EBV positive graft. An acute EBV virus infection is typically associated with severe malaise and fever and flu-like symptoms i.e., infectious mononucleosis. Other evidence of EBV infection can include an increase of liver function tests, splenomegaly and lymphadenopathy. In certain instances an EBV infection can progress to a post transplant lymphoproliferative disorder (PTLD) which can develop into a malignant lymphoma. Surveillance for PTLD should therefore began immediately following the transplant particularly in EBV negative recipients who have received EBV positive grafts. PCR has been utilized to semiquantitatively monitor EBV replication by quantitatively determining the amount of EBV encoded RNA (EBER) in the serum as an early warning of an impending PTLD.28 Other approaches using in situ hybridization have also been described.

While there is no standardized strategy for preventing PTLD, two basic approaches have evolved. One approach is to give long term prophylaxis with recipients maintained on ganciclovir and/or IVIG for 3 to 12 months following the transplant. The other approach is to have a shorter period of prophylaxis (2 to 6 weeks,) followed by surveillance as described above and preemptive therapy should surveillance identify increased EBV replication. Similar strategies are also used or CMV surveillance.

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